Case of a 16 Year Old Male That “Can’t See, Can’t Hear”

1. Case of a 16 Year Old Male That “Can’t See, Can’t Hear” Teresa M. Carlin, MD Assistant Professor Department of Emergency Medicine and Pediatrics Johns Hopkins University Baltimore, MD

2. Case Presentation • 17 yo male presents to the ED • CC: “I can’t see” • triage assessment: • normal vital signs • grossly normal vision • outcome: • left waiting room prior to physician evaluation

3. Case continued • Represented to ED 24 hours later • CC: “can’t see, can’t hear” • triage assessment: • normal vital signs • grossly normal vision • grossly normal hearing

4. History • Source: per patient • CC: can’t see and can’t hear • could not elaborate further • ROS: • denied recent illnesses • denied nausea, vomiting, diarrhea • denied fevers, chills, URI • denied rashes • occasional headache

5. History • PMH/PSH: unremarkable • Medications: none • Allergies: none • SH: • has one child • lives with mom • occasional ETOH and marijuana • denied other illicit drugs

6. Exam • Bright and alert • walked into the treatment area without difficulty • VS: 37.5*C, HR=72, BP=130/70, and RR=14

7. Exam • HEENT: • EOMI and without nystagmus • muddy sclerae • pupils mid-sized and reactive • TM’s normal bl • NECK: • supple • no adenopathy • no bruits

8. Exam • CV: • regular rate and rhythm • no murmurs, rubs, or gallops • nondisplaced PMI • RESP: • CTA • unlabored

9. Exam • Abdomen: • soft, nontender, nondistended • negative masses or hepatosplenomegaly • normal bowel sounds • Skin: • negative purpura, petechiae, rashes, or track marks • several tatoos on arms and back • Extremities: • well perfused, no edema

10. Exam • Neuro: • alert • normal gait • equal strength throughout, normal tone • followed simple directions: • could see and pick up a pen and identify it • asked in normal tone of voice

11. Exam • Neuro: • directions frequently repeated • ‘huh’ and ‘don’t know’ • typical teenage behavior? • seldom used full sentences • yes, no responses • unable or unwilling to cooperate with further exam • annoyed and frustrated • “going home”

12. After Exam • Patient jumped off gurney • found restroom without assistance • returned to treatment room without difficulty • later found wandering in the hallway • “Huh?”, “Huh?”, “Waiting for my mom” • redirected to room • fell asleep

13. Cousin’s History • Normal state of health until 2 d PTA • 2 d PTA : • arrested for possession of marijuana • head banging while in cell • choked??? • released to custody of mother early morning • not acting like self • jail experience

14. Cousin’s History • 1 d PTA: (first ED visit) • awoke c/o “headache” and “can’t see” • sleeping ALL DAY LONG • squinting and intermittently covering one eye • bumping into things at home • did not make sense when he talked • not acting like his normal self

15. Summary • 17 yo male not acting right • headache • “can’t see, can’t hear” • not cooperative with exam • teenager or pathology • 2nd ED visit for same complaint • change from baseline mental status • sleeping a lot • not making sense when he talks

16. Questions? • What is the differential diagnosis? • What initial laboratory tests should be drawn? • What ancillary studies should be ordered?

17. Infection meningitis encephalitis sepsis Toxic toxicity/withdrawal environmental Metabolic lytes, endocrine liver, kidney Cerebrovascular trauma space occupying lesion seizure related stroke hemorrhage Psychiatric psychosis severe depression Hypoxia/hypercarbia Altered Mental Status Common Causes

18. Pulsox, d-stick Blood Work CBC, Electrolytes, BUN/Cr, glucose LFT’s, Ca, Mg, Phos Blood Cultures ABG Head CT Toxicology urine and serum tox screen ua, micro, C&S EKG, chest xray If above negative, consider LP Emergent Evaluation

19. Results • All blood work is NORMAL • EKG and CXR are NORMAL • Tox screen is positive for THC

20. Evaluation continues • Patient instructed to get into wheelchair for head CT • Patient responded (fluently): • “Chairboot flies to the baseball” • Cousin responds: • “that’s what he has been doing” • “he ain’t making no sense” • Do you expect the CT to be abnormal?

21. Head CT Results • Head CT/MRI are ABNORMAL • bilateral watershed strokes • between MCA and PCA distributions • left frontotemporal parietal lesion • watershed between MCA and ACA

22. ED Management of Pediatric Stroke • Extrapolated from adult literature • IV, O2, and monitor • prevention of stroke evolution: • ASA therapy • anticoagulants - likely benefit if: • arterial dissection, prothrombotic disorder, • dural sinus thrombosis, embolic source identifiedthrombosis

23. ED Management of Pediatric Stroke • too late for thrombolytics • CT evidence of stroke • symptoms for at least 48 hours • usefulness in pediatric stroke????

24. Hospital Evaluation • ASA therapy • MRI, MRA, MRV • echocardiogram and bubble study • valves, thrombus, PFO • transcranial and carotid duplex

25. Hospital Evaluation • hypercoaguable studies • PT/PTT, INR, Factor V leiden, homocysteine • protein C and S, antithrombinIII • anticardiolipen antibody • HIV testing • Lumbar puncture

26. During Hospital Course • Wernicke type aphasia • visual agnosia • fluent speech, poor content + circumlocutions • impaired naming of visual stimuli but ok with tactile stimuli • semantic paraphrasias and neologistic jargon • normal motor exam

27. Outcome • Etiology of stroke never identified • Theory: • acute occlusion of bilateral carotids by manual pressure • ? Strangled in jail • Progress: • continues with visual perceptual problems • aphasia that interferes with his ADL’s • impaired auditory comprehension